Treatment Issues: Newsletter of Experimental AIDS Therapies - Volume 17, Number 7-8, July / August 2003
Bob Huff

The accessibility of quality HIV care, with and without antiretroviral therapy (ART), varies widely across the globe. As drug prices have fallen in resource-poor areas, dozens of small pilot programs are now proving that that therapy is effective, feasible and subject to problems familiar in the rich countries. Meanwhile, in the U.S., several hundred thousand people are estimated to have HIV and not know it or want to deal with it. Many of these people have limited access to care and may finally enter the system only after symptoms develop. Barriers to care, such as stigma, lack of knowledge, and lack of money, cut across hemispheres and time zones.

At the International AIDS Society’s 2nd IAS Conference on Pathogenesis and Treatment, held in Paris this summer, 17 abstracts reported on the experience of treating over 2,400 patients with ARV in 11 countries in Sub-Saharan Africa. Additional reports of successful treatment programs in Latin America and Asia peppered the conference abstract book. This is up from the handful of papers presented at 2002’s much larger International AIDS Conference in Barcelona. Clearly a lot has been accomplished in the intervening 12 months, but of the estimated 300,000 people receiving ART in the developing world, half are in Brazil and fewer than 30,000 are thought to be on treatment in Africa. With at least 4 million people in need of treatment in that region alone, the often-stated goal of treating 3 million worldwide by 2005 seems to be slipping out of reach.

Not so, says Paulo Teixeira, the architect of Brazil’s successful ART program who has just taken over as the new chief of HIV/AIDS at the World Health Organization (WHO), the body that set the target at 3 million. “My belief is that it is absolutely feasible, despite the magnitude of the task,” Teixeira told Reuters. The daunting reality is that achieving WHO’s goal means treating 100,000 new people every month from now until the end of 2005. Yet, despite the slow pace to date, there are signs that treatment programs are poised to accelerate as costs decline and funding increases. Here are a few selected reports from the Paris conference that sketch the outlines of what is possible and where problems persist.

Generally, the reports of pilot treatment programs tell stories of improved CD4 counts, fewer deaths and fair adherence. At the 2002 International AIDS Conference in Barcelona, the Heineken brewing company reported that providing ART to employees and spouses was affordable, if not strictly justified on a cost/benefit basis. A year later the company has presented an analysis of changing costs in AIDS-associated medical expenses, absenteeism and death after the institution of their treatment program at a brewery in Burundi. They now find that the benefits do justify the costs.

Thirty-one persons have started treatment since the Heineken program began in September 2001. Hospitalization for opportunistic infections declined from an average of 20 per year (1997-2000) to 10 in 2001 to only 6 in 2002; deaths declined from 11 to 2 to 1 during the same periods. Time off due to illness also declined. Meanwhile, voluntary HIV testing increased from an average of 13 per year (1997-2000) to 123 in 2001 and 140 in 2002. Overall costs were 58,188 euros ($66,000), including 47,207 for drugs, 7,927 for travel and training, and 3,154 for diagnostic tests. Overall, medical expenses increased by only 5,233 euros between 2001 and 2002, suggesting that the costs of treatment were almost entirely recovered by savings in hospitalizations and other losses. (Gahimbaza)

But government involvement will be essential if treatment programs hope to reach the huge numbers of people without jobs or family income. In Cameroon, with nearly 1 million infected, the government is now providing ART for 7,000 people. Médecins Sans Frontières (MSF), the international medical organization, reported on a collaborative pilot project in a military hospital in Yaounde that has treated 117 people since 2001. With effective therapy and good monitoring, and despite advanced disease in many patients, the authors observed outcomes comparable to those obtained in rich countries. (A complete listing of worldwide MSF ART programs is on page 7). (Mougnutou)

A researcher at a care center in Mumbai, India reported on the struggle to provide antiretroviral drugs to people who need them when few can afford them. Simply following the “Hit Early, Hit Hard” paradigm, he says, would result in bankruptcy. To accommodate the reality of limited resources, the author studied ways to modify treatment protocols, dosages, combinations and follow-up to increase affordability, adherence and survival. During the period from 1995 to 2002, 4100 people with HIV/AIDS were managed by the clinic, and although 943 were eligible to receive ART by local standards, only 570 could afford generic drugs. Most who began drug therapy took an NNRTI and two NRTIs; the rest were given supportive therapy and treatment for symptoms and opportunistic infections (OI). “CD4 count, clinical status, incidence of OI were studied, but viral load was dispensed with.” Further cost-saving measures included extending the follow-up interval by an average of 3.7 months and reducing dosages by 25–50 percent according to body weight. The author observed no difference in outcomes between patients treated on this austerity plan (about $30 per month) and those who received a PI-based regimen. In this clinic, lowered drug prices, reduced follow-up costs and simplified patient care protocols resulted in improved access to ARV. (Gilada)

While costs may be managed, and affordable ART delivered where there are institutional or corporate resources, the situation when individuals are on their own is not as bright. One study looked at the economic status of those who able to receive ART in Cote d’Ivoire. Not surprisingly, higher personal income was associated with greater access to treatment. Physicians conducted interviews with 173 patients receiving ART in five outpatient clinics in Abidjan during a four-day period in November 2002. The patients had a median age of 34 years and had been attending the clinic for a median 9 months; over half were women (59%). Of those surveyed, 23 percent had no personal income; 37 percent received less than $76 per month; 26 percent received between $77 and $288 per month; and 14 percent had incomes over $288 per month. Of those with incomes, 61 percent were employed, while the rest reported receiving an allowance from relatives. The 31 patients (18%) taking ARV had a significantly higher monthly income than those not being treated (>$76 monthly: 68% vs. 48%, P=0.05). Only 2 patients received ARV for free. The rest had to pay for all or part of their medication, with 46 percent paying up to $45 per month; 41 percent paying between $46 and $107 per month; and 14 percent paying more than $107 per month. Relatives contributed to ARV costs for 45 percent of those surveyed. (Sauvageot)

But there are barriers to receiving care beyond affordability, among them lack of empowerment, lack of knowledge, social stigma and fear of disclosure. HIV-positive women in Lusaka were asked via questionnaire about how accessible they perceived HIV therapy to be for them. Seventy-one percent had heard about antiretroviral therapy but did not know exactly what it was; and 14 percent had purchased drugs — usually Indian generics — and were taking them. The expense of medications was the most common reason given for not buying ARV (85%), with 62 percent saying they would rather spend the money on household expenses. About a quarter of the women said they had not disclosed their HIV status to their partners for fear of being blamed for bringing the disease into the household. Two-thirds of the women said they were dependent on their spouses for income and 72 percent said the felt the traditional role of women in society was a factor in making it difficult of them to obtain access to treatment. (Shumba)

Provider knowledge may be another barrier to effective care, even where drugs are available. India is a huge, sprawling country with many cultural traditions that include a range of practitioners of different medical systems such as ayurveda, homeopathy, Unani, naturopathy, and modern Western medicine. With over 4 million HIV-infected persons in India, many of these doctors are increasingly called upon to practice HIV medicine. A researcher from a government hospital conducted a survey among 300 family physicians and 60 consultants from both high- and low-HIV prevalence regions, concerning their level of knowledge about providing antiretroviral therapy. About three-quarters of the participants were modern medical practitioners, 20 percent ayurvedic physicians and 8 percent homeopaths. In the low-prevalence states, 99 percent had no knowledge of the parameters for initiating HIV therapy and 70 percent were unaware of diagnostic tests. Although 70 percent had heard of AZT, there was no knowledge of adverse drug reactions, patient monitoring or pre-therapy counseling.

In high-prevalence areas the results were somewhat better, though still abysmal. Although 80 percent of doctors were able to write the names of two or three drugs, the majority were unaware of parameters for starting therapy. And although most had heard of the CD4 count as an HIV test, few understood the significance of CD4 results. The author notes that physicians in India often prescribe antiretroviral therapy “to pacify the patients without proper protocol or scientific basis,” thereby risking the development of drug resistance. Currently, there is no laboratory in India to detect or monitor emerging drug resistance. (Deshpande)

And lest we think that drug access disparities only occur in faraway places, the San Francisco Department of Health reported on the uptake of a new generation antiretroviral, tenofovir, in a setting where free treatment is guaranteed to all who need it. Using citywide surveillance data, the authors conducted a retrospective review of 6,898 people living with AIDS during the period of 1999 to 2002 and identified 403 (5.8%) people who had ever received tenofovir. About a quarter of these had received the drug prior to approval, which suggests participation in a clinical trial or expanded access program. Those never receiving tenofovir were more likely to be non-white, injection drug users, homeless and have no insurance. Individuals from upper-income areas were more likely to have had access to tenofovir than those from lower-income areas. The authors concluded that their “findings highlight a disquieting inequity of the American healthcare system that cannot be corrected simply by making AIDS treatment affordable or free.” (Chen)

Finally, as a counter example to the situation in India and elsewhere, one can look to the description of a model, comprehensive primary care HIV clinic provided by the Community Health Network of Rochester, NY to grasp what state-of-the-art care can entail. Started over 13 years ago, the federal, state and locally funded clinic serves about 800 patients with five HIV specialist physicians, six social workers and two aides, five clinical nurses, a research nurse, a care coordinator, a dietician, and a treatment adherence counselor. They also have available a psychiatrist, a therapist, a gynecologist, an optician and a part-time pharmacist. (Perhaps some of these experts would volunteer to spend next winter teaching in sunny Lusaka. Contact the International HIV Clinician’s Exchange Program: www.iceha.org) Also important to note is the patient-centered approach to care that the Rochester clinic supports with services such as issue-driven patient group meetings, a patient care-committee and a patient library. (Corales)

Access to care depends on many factors ranging from income to empowerment and from price to patient and provider knowledge. As drugs become more available, access to information and commitment to equitable availability are emerging as crucial factors for obtaining good outcomes from HIV care, wherever it is provided.

References

All abstracts are from The 2nd IAS Conference on HIV Pathogenesis and Treatment, Paris, France, 13-16 July, 2003 and are published in Antiviral Therapy, Volume 8, Supplement 1, 2003.

Gahimbaza L. Costs and benefits of the antiretroviral therapy in the private sector: the experience of Brarudi, Burundi. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 668.

Mougnutou R. Evaluation of a HAART pilot study in Yaounde, Cameroon: 24 months follow-up. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 686.

Gilada I, Comprehensive cost-efficient model of HIV care from India most suitable for resource-poor settings. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 639.

Sauvageot D. Access to antiretroviral (ARV) drugs in five outpatient clinics in Abidjan, Cote d’Ivoire. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 642.

Shumba CD, Kwalombota M, Accessibility of HIV therapy to women living with HIV/AIDS in Lusaka, Zambia. The 2nd IAS Conference on HIV Pathogenesis and Treatment, Paris, 2003. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 772.

Deshpande A. Is India poised for HAART? IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 569.

Chen SY. Disparities in community uptake of tenofovir in San Francisco, California. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 643.

Corales RB. The comprehensive HIV primary care clinic model: one stop shop. IAS Conf HIV Pathog Treat 2003 Jul 13-16;2nd: Abstract No. 648.

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